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Palliative Care Networking Group:
Bridging the Gap Toward Smoother Care Transitions
Presented by [Darla Waldner, Executive Director of the Land of the Dancing Sky Area Agency on Aging]
(52-minute Webinar) [date e.g., 05-02-2013]
Janelle Shearer: Hi everyone, I’d like to welcome you to the Palliative Care Networking Group. Our
speaker today is Darla Waldner. She’s presenting on the topic: Bridging the Gap
Toward Smoother Care Transitions.
She is Exec Director of the area Agency on Aging and has worked for the Land of the
Dancing Sky Area Agency on Aging for the past 9 years in the area of agency program
developer. The primary focus of her role is to develop critical home and community
based services that have a high impact on older adults and their caregivers, that are
affordable and accessible.
Darla has over 20 years experience as a social worker in the field of aging. She has
held both clinical and administrative roles, including: social services director in a longterm
care facility, director of home and community based services and case manager.
Darla is passionate about creating communities that last a lifetime and support older
adults and their families in remaining independent and living in the home of their
choice.
In February of 2013, she was promoted to Executive Director of the Land of the
Dancing Sky Area Agency on Aging. I love that name. The agency services residents in
a 21 county planning and service area. She and her husband and three children, are
planning to relocate to the northern part of Minnesota to be closer to the administrative
offices located at the Northwest Regional Development Commission.
Everyone should have received an email from me with a handout and FAQs.
Darla, it’s nice to have you with us today. I’m going to turn the program over to you
now.
Darla Waldner: Good morning everybody. I’m excited to be here today for both professional and
personal reasons. I want to let you know that I’ve been a big champion of rural palliative
care for personal reasons. Five years ago I went through a serious cancer and there
was a team of doctors, social workers, and a chaplain that supported me and my family
through that process.
It stressed the importance early on of documenting my health care preferences and
making my choices about health care, as well as making sure that I’m empowered and
that I’m the one that makes those decisions. I was very excited when I heard about
Stratis Health’s grant opportunity and the chance to work with partners out in our
community.
Many of them are on the phone with us, so that’s exciting.
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For professional reasons, at the Land of the Dancing Sky and with my counterparts
across the state, what we’ve all been trying to accomplish in the field of health care is
designing a system that supports older adults in our case and young adults as well. But
for older adults living independently in their home and giving them tools to be able to
manage the illness and age in place.
We can’t do that alone, so we learned early on that collaboration is a successful model
for being able to provide that safety network.
The Land of the Dancing Sky has 21 counties and we’re all in the northwest side of
Minnesota. It’s 385 sq. miles in that service area and sometimes that’s a daunting task.
We talk about rural palliative care in our 21 counties, all of them with the exception of
the community of Moorhead, according to the state demographic society are
considered rural. So this really speaks to our language.
We talk about bridging the gap for older adults. We talk about putting that safety net
around them and before we do that we have to understand some of the demographics
in our state and together how can we accomplish that task.
I’m sure many of you are aware of the silver tsunami statistics or the dot in the age
wave that is facing many of our communities. The reality is that between 2005 and
2035, people 55+ will double from 600k to 1.3 million older adults in our state. Eightyfive
plus population will nearly double to 163k, and what do we know about that? As
older adults age, their disease progresses and that impacts all of us in this room and
our impacts our ability to provide for those diverse needs.
By 2020 there will be more people 65+ than school age children. What does that say
about the amount of caregivers that will be available to meet these needs?
The next slide is a good visual about the growth we’ve seen in the 85+ population,
starting in 1990 when we were below the 80k mark and slowly going towards the top. It
basically says that we’ll be overwhelmed by this population and that we need to be
ready as communities to serve them.
Income diminishes as one ages, which puts yet another stressor on the system. The
poverty rate for 65+ is 8.3% in the state of Minnesota and a poverty rate for 75+
increases to 10.3%. Elders of color have a higher poverty rate. What’s known as a
staging for older adults in the state of Minnesota is the medical assistance program.
Currently the program serves the long-term care needs of just over 5% of Minnesota
seniors, a relatively small population.
Minnesota’s relatively modest medium income level results in a large number of older
adults, who will need support outside that safety net. Because of the impact that a small
percentage of seniors will be eligible for medical assistance, will be critical for us to
build bridges so these people are able to cross multiple health care settings with
pathways that can be created through rural palliative care and bridge through senior
linkage line and the areas agency on aging as well as other home and community
based partners.
One of the key roles that the Area Agency on Aging plays is in the area of development
of home and community based partners that are critical access services.
What do we know? We know the vast majority of long-term care starts at home.
Minnesota has had a strong network of service providers that deliver low cost, high
impact services, chores, homemakers, grocery shopping, meals and transportation are
all just examples of that.
The thing I love about working with our rural partners is that collaboration isn’t
something that’s new to us.
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The foundation of all the organizations we work with were built on the successful model
of collaboration, so I feel it’s a skillset we’ve been born into. Other things we need to be
aware of within the field of home and community based services I can’t stress the
importance enough that we can’t do this without the family and friends providing
assistance to older adults.
Even a 1% reduction in family assistance equates to $30 million increases in the state
budget. That’s huge, that’s not small change. Increasing the supply and the types of
caregiver support services and activating informal networks is critical. At the areas
agency on aging we have taken a strong role in the area of caregiver services and we
provide funding for several programs as well as caregiver coaching. A lot of care giving
isn’t just a six month span of life, it can be a long journey and we know that often
caregivers end up becoming sicker than the folks they’re caring for.
So it’s critical to have this caregiver coaching program that can walk hand-in-hand with
them. Sometimes they aren’t ready to have care because coming into their homes
seems huge to them. So having the caregiver that can be a resource to them, support
them and provide them with the tools to manage, this practice is critically important.
Let’s talk about Area Agency on Aging elder care development partnership. When
Janelle said I worked for the Area Agency on Aging for nine years it’s actually been in
this role that I worked in prior to February of this year. It’s something I’ve been very
passionate about. For the past 20 years the Area Agency on Aging partnership has
played a critical role in developing home and community based options.
The reality is that in rural northwest Minnesota and parts across our state, we don’t
have multiple providers. We have providers, might be one wearing multiple hats,
because that’s what they need to be in the community’s they serve. We’ve worked with
many of our local partners to identify and develop the gap analysis process as well as
needs assessments and what the things are that are lacking in those communities and
pulling the partners together.
We’re doing some pretty incredible things on $20k budgets in a lot of these
organizations, which are very much volunteer driven and have a huge impact. They’re
saving a lot of money, but most importantly all their adults are allowed to remain in their
homes.
One of the areas that we work with is with local aging resource centers. The Area
Agency on Aging, that was created under the Older Americans Act, has a statewide
home and community based network that develops and delivers non-medical services
to help older adults remain in independence at their homes.
When we talk about the designs of Minnesota’s aging network what we’re talking about
is that it’s designated by the Minnesota Board on Aging. There are six regional area
agencies on aging and one tribal Area Agency on Aging. Some of the roles they play
are stewards of federal and state funds. They are experts on community services, care
giving, volunteer support, housing options, Medicare and public benefits.
More importantly, I can tell you that I know many of these individuals on a personal
level and they truly care about the elder adults they’re serving. They help organizations
for local vendor networks as well.
Let’s discuss how the Areas Agency on Aging impact the care transition process. One
of the areas that we can have an impact and have been successful in is consulting one
to one with older adults and their families about services, housing choices, caregiver
support, Medicare benefits and county services. That’s a daunting task but it’s providing
them with long-term care option counseling that encompasses from finding someone to
clean their home to helping them understand long-term care insurance.
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It helps older adults transition across care settings. We take a big role in advocacy in
that area as well. Identifying needs and distribute federal and state resources to fund
services for seniors and caregivers. In that role we are a grant administrator for Older
Americans Act dollars that provide services to entities on a funding formula. Some of
those services are in the community’s served so we fund Meals on Wheels, Caregiver
and other services, homemaker chores, transportation programs, as well as legal
services and evidence based programs such as a Matter of Balance and trying to be
self managed in living with a chronic condition.
We are also partnered to develop effective services and programs. A lot of what we’ve
done under that umbrella is during these economic times everyone is getting cuts in
funding that the high cost of inflation is impacting to many of these programs that are
driving huge distances. Their travel time and mileage is no news, I’m speaking to the
choir on this subject, it’s eating up budgets that are already thin.
So a key role we’ve taken on is helping these organizations sustain themselves and
helping them figure out what that pathway is beyond their walls and who needs to sit at
their table so that together they can merge and address the issues.
One of the things we’ve been most excited about as a state is our senior linkage line,
which is a toll free information assistance line, a consultation by telephone, a web chat
or at home. The computer systems and technology that they use for this is remarkable.
They can do live chats, transfers when an older adult calls. It’s not like Medicare or
Social Security where it’s push one button and you’re transferred with lovely elevator
music and you’re on the line for 20 minutes, oops you were disconnected.
That’s frustrating for me and I have adequate hearing and I’m very assertive with my
needs, but imagine an older adult that can’t hear well and might be dealing with
memory loss issues where trying to use a telephone system is huge. Through the
linkage line they’re able to evaluate complex living situations, connect to housing
options and services such as homemaker meals and transportation, medication
management, home modification and wellness programs. They also answer Medicare
and insurance questions.
Some of the tools for older adults to figure out are on the web. What do we know about
older adults? That the 85+ population very seldom even know how to turn a computer
on, although we are making gains. I think the baby boomers will change that dynamic in
our lives. A lot of those tools again are web based, so the senor linkage line is key and
the good thing is that it’s unbiased so they aren’t linked to a financial source, they’re
just helping them understand the sources that are available out there.
Also, follow up is very much part of the senior linkage line. When an older adult or a
family member accesses the line and go through the process of reviewing the options,
there is follow up afterwards to make sure the process and their needs were met and
see if there are any further needs to be met in the process.
The senior linkage line was created for one stop for answers on aging. I can’t tell you
how many times I sit across the table from older adults and they’re tired and worn out
and we ask them their story and they say do you realize you’re the 8 th person this week
I told my story to? How frustrating is that? They have to tell their story when they sign
up for home health. They have to tell their story when they go to the physical therapist.
They have to tell their story when the homemaker and chores services show up. This is
their answer, one stop for answering on aging.
It is the information assistance line, Monday through Friday 8:00 to 4:30 and yes I
recognize that not all problems occur during those days and times, but the options are
there and available.
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If you’d like more information on the Minnesota Area Agency’s on Aging I’m providing
you with all the information, including all the AAA across our planning and service area.
I also wanted to bring attention to the other handout we provided, which was developed
by M4A as a service for seniors in-service network. In the boxes you can see some of
the programs that are supported both informal and formal networks across the planning
and service areas.
This is actually a good tool and handout to give to older adults when they’re trying to
understand the services that are there. I can’t stress enough the importance of the
collaboration between the Area Agency on Aging and the palliative care networks. With
the things that are going on in federal and state with healthcare home process and
models as well as the hospitals with the readmission rates and some things that are
going on with the projects across our states, it’s where the formal and informal
healthcare systems have to come together and create a system that’s seamless for
these older adults as they transition across healthcare settings.
I know the Area Agency on Aging is a small piece of that pie but we feel it’s necessary
to be at that table and help put these collaborations and bridges together.
Let’s open up for questions…
Janelle Shearer: I’ve heard of Meals on Wheels and Area Agency on Aging, but now that the regulation
for hospitals to call the senior linkage line is when someone is at risk. It’s like a well
kept secret.
How does it really work and are these services free for people?
I know Meals on Wheels isn’t because my parents had that and had to pay for their
meals, but if you could tell us how it works for folks who need things.
Darla Waldner: I agree it’s one of the best kept secrets, so that was a nice way of putting it. We receive
referrals from multiple points of entry in the system and hospital and discharge planners
are key referral sources for that. Now it’s even being mandated that that partnership be
strengthened.
How it works is that we have a wide variety of home and community based service
providers, some of which are grantees of the Older Americans Act dollars that we fund
through all our Area Agency on Aging. Some are partners that we provide technical
assistance to through grant writing and community service development grants as well
as private foundations and other local funding opportunities.
Under the Older Americans Act, it’s based on people’s ability to pay and nobody is
denied services, regardless of their ability to pay. We do emphasize with our community
based partners that they provide the opportunity for older adults to share in their
services and I think that’s something collectively that we all need to get that message
across is that services can’t be provided for free and that whatever ability to pay for
services that should be allowed the opportunity to contribute.
Many of our rural partners were built upon faith based initiatives or have been built on
volunteer networks, so sometimes they struggle with how we encourage people to
donate and does that impact our mission? We’re trying to work with them on saying you
can build your capacity by allowing the opportunity for cost sharing of those services
and many of these organizations are dependent upon grants, but they are decreasing
also. They have to find some multi-diverse funding sources which is critical.
Janelle Shearer: So, is it folks that are down to the level of medical assistance?
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Darla Waldner: Absolutely not. We have access and provide services from people that are on the
elderly to alternative care programs, on up to providing services to Donald Trump if
need be. The Older Americans Act is more targeted to those individuals that are just
above qualifying for medical services that in between group that’s struggling with high
healthcare costs and just meets the needs of that population, but the services we
provide encompass all different economic groups.
Janelle Shearer: So, when they call the senior linkage line if they determine they need
housekeeping and laundry services, then does senior linkage line refer them to
an agency that provides those services?
Darla Waldner: Absolutely. We have a wonderful web based tool that I want to promote called
MinnesotaHealth.info that everyone has access to. By the way, I want to encourage
you as organizations to get on there and check your own link on there. It’s free
advertising for everyone. Make sure you have all the programs you’re utilizing on there
because what happens especially in our rural community, their children aren’t living
next door anymore they’re living in St. Paul, Bloomington or the California daughter or
Texas son so them getting access to services, unlike the 85+ population is very much
web based. Having your links up on information and referral is key to those individuals.
Janelle Shearer: All your organizations are on there?
Darla Waldner: There is a toggle on the website where you can go in as a provider and update your
information. There’s a search button so if you’re home health you can put that in, as
well as the community you’re in and it should pop up, if you’re a registered service or
licensed through the state of Minnesota, you can almost guarantee you’ll be on there
somewhere.
It’s important. We promote Minnesota Health, but we can’t make those changes for all
organizations as well as update them.
Janelle Shearer: Is that what the folks at senior linkage line use when they’re providing
information?
Darla Waldner: They’re looking on the web but a lot of times informal providers, not just the larger
organizations, sometimes in some of our rural parts its Jim Jones that lives by the
grocery store that you know you can call and they’ll shovel grandpa’s driveway.
Sometimes it’s informal like that and that’s how it is in our region very often.
A lot of our communities have resource directories as well that have been put together
by local providers, which are also handy tools.
Guest:
So you get referrals from multiple entry points. At Crane West all of our seniors have
had the assessment to know their placement is appropriate or so we hope and then
appropriate referrals many served by the waiver or not.
If you get a referral from someone who doesn’t have that luxury do you then
make referrals for the county assessment?
Darla Waldner: Absolutely. That’s very much a part of our intake process. They have specific protocols
that they follow on the senior linkage line that gets to the heart of that and if that’s the
direction they need than a referral is made. The exciting thing is that they can be on the
phone with the older adult, identify the problems and needs and do a three-way call to
the county with the adults on there to make that transfer and get to the right person.
Then once they get on the line senior linkage can get off and has made that smooth
connection.
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Janelle Shearer: I would expect once that referral is made than those people are the ones who make
referrals for all the other services. You don’t need to individually refer them for all the
services that case managers can do?
Darla Waldner: Correct, but sometimes the older adult or caregiver doesn’t even know what services,
they don’t know if they’re in the system or not or some of those things. The staff is good
about saying, can you get out your card and tell me what’s on the card to understand
where they are. So a lot of times we do make referrals.
Janelle Shearer: So all the calls go through the linkage line?
Darla Waldner: They do. How the linkage line works is that all the area agency’s on aging have call
centers so, depending on where you call in part of the state it will be initially routed to
the call center in that region, but when things are busy you want to give access to older
adults in a timely fashion so then someone from an office call center could take a call
from there. Typically, from Hover County north it goes to the Warren office and the
other part of the region is routed another way, so there is similar capability across the
state.
Sherry Dale:
You made a comment about some of the funding things and one of those was
respite, does Area Agency on Aging help fund respite or do they just help find
ways for people to help fund their respite?
That’s a big need we see that’s hard to get funded or even to find people to do the
respite.
Darla Waldner: Each of the Area Agency’s on Aging do have their Older Americans Act dollars and
specifically the title of dollars we’re talking about is Title 3E, do have providers that fund
respite care. Traditionally it is a non-medical respite care and that is where the
caregiver would need four-six hours out of the home to do something.
I think the gap in service what is needed is the overnight and weekend respite care,
because those tend to be things our providers have done on a case by case basis, but
it’s a real struggle when you’re doing a volunteer non-medical model to fit that niche. So
to answer your question yes we do, we fund that as well as link them to pro\grams.
Sherry Dale:
Thank you.
Janelle Shearer: This is a national program right?
Darla Waldner: Yes.
Janelle Shearer: Does it look different in different states what services are provided to the Area
Agency on Aging?
Darla Waldner: One of the things that’s unique to our area is the senior linkage line and it’s the shining
cap of Minnesota. Other than that the administration on aging sets key initiatives that
need to be accomplished and that’s the Development of Critical Access Services and
critical access around nutrition, caregiver respite and support, homemaker chore and
transportation services and personal emergency response systems.
That’s a big piece of the puzzle, as well as our Title 3E funds are targeted towards
evidence based programs. I think of any area of program development we have seen
huge explosion across our state is in the area of evidence based programs such as a
Matter of Balance.
Fall prevention is huge. In the state of Minnesota it’s the third leading cause of death
and some of us can say okay we just experienced the longest winter of our life and that
could have some factor in it, but I believe Florida and Arizona are the two states ahead
of us with larger concentrations of older adult population.
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It’s the number one reason for nursing home placement, a fall. It hugely impacts
people’s lives and one of the programs we’ve developed is a Matter of Balance, which
is an evidence based program, but not only do older adults learn key exercises to
develop flexibility and work on their core body and strength, but it also addresses those
fears of falling. It’s the older adults sitting in the recliners with their Reader’s Digest and
balls of yarn that are all toppled over that are paralyzed from fear of falling.
This causes them to isolate themselves in their homes and ironically the number one
place you fall is in home. That program has been really successful in getting people out
of their recliners and starting them back into some type of exercise program. The piece
I love about it is that it also does a comprehensive home safety checklist. These aren’t
PTOT assessments, but it helps them to identify the common things in their home
because much of what we’ve found in our planning and service area, one of the biggest
items for being at risk for falls happens to be their durable medical equipment.
I chuckle because we’re brilliant out here as healthcare systems but the majority of
oxygen cords are see through and older adults can’t see through them. So hearing
what some of the older adult population are very creative. They’re blackening it with
markers and doing all kinds of things to address that because it ends up being a fall
hazard, as well as not using your equipment properly. So Matter of Balance has been
huge with physical therapists and it’s been the first program that I haven’t been begging
people to do, people have been calling us to do it.
The other thing is Living Well with Chronic Conditions, which is a six week workshop
that actually helps people become their own self managers. Core skills that they’re
learning is how to have those conversations with your doctor and healthcare
professionals? How do you plan for agency in place as your disease progresses? Have
you documented those preferences on a healthcare document or what is appropriate?
We talk about how the pain affects them, fatigue and medications, all of those pieces
are involved so it’s been a huge program. Our strategy in the Area Agency on Aging is
looking within the health system to recruit volunteers to lead these classes and it’s been
a successful model. Now we’re starting tai chi and I’m excited about that.
I’m happy to be wrong. When I first said Matter of Balance jumpstarts you into fitness,
but it’s not like bone builders or some of the programs you see at the Y where it’s
ongoing. Tai chi is ongoing and when my staff first brought it up I said we are not
getting these northern Scandinavians to participate in this and they looked at me and
said you wait. I just had an attendance sheet from Lake Park and there were 17-18
people on there.
Janelle Shearer: So the Living Well with Chronic Conditions is a six week class where people come to a
classroom setting and learn about things. What about Matter of Balance?
Darla Waldner: It can be an eight week class and these are two and a half hours with the Living Well
with Chronic Conditions class and sometimes people do it for four weeks twice a week
or eight weeks once a week. We do have Land of the Dancing Sky has master trainers
in these curriculum and evidence basically means there’s been a long study by some
medical model that’s been good data collection and researched base.
We provide the train the trainer classes throughout our planning and service area and
we also provide fidelity monitoring, because evidence based means you have to have
two trainers teaching the curriculum. You teach the curriculum as is, so sometimes as a
social worker I might have other knowledge about family systems and those pieces, but
you really have to focus on the curriculum and teach it as is, and nurses sometimes
struggle with that.
They have a whole section on orthostatic hypotension, so you have a whole other
knowledge, but the monitoring is that you teach what’s there.
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Janelle Shearer: And you said there was an in home component where there’s a home assessment.
Is that a one-time thing?
Darla Waldner: Yes. I want to clarify they are either doing it themselves. We encourage them to bring
their families or whatever their support network is and prioritize these. There are a lot of
things that can be fixed. We do a good job of putting lights in our bathrooms, but our
long hallways in older adult homes aren’t necessarily up to code as we know and some
of those things are inexpensive to fix.
I think the most difficult thing is getting them to let go of their pretty rugs. We encourage
it to be family oriented. The kitchen is one of the main areas other than the bathroom
where people fall because things are out of their reach, it’s not safe, so if you’re doing it
with your support system they can help put the bread maker up high and organize the
kitchen a little.
Janelle Shearer: If somebody in any community throughout Minnesota called senior linkage line
and said I’m afraid of falling, then they can get hooked up with the Matter of
Balance program?
Darla Waldner: Absolutely.
Janelle Shearer: So every community has that available?
Darla Waldner: I wouldn’t say every community. In our 21 counties I would say that 15-16 of them have
one or more of these services, but some they do twice a year, some only once and that
kind of thing. If you call us than we can get you in touch with a local program. There’s
also a website called MinnesotaHealthyAging.org that has these classes listed, so you
can go there to find out when a class is happening.
Janelle Shearer: So even if you lived in the southeast part of the state you should be able to find a
program like that?
Darla Waldner: Absolutely.
Janelle Shearer: Is this done by your staff? You mentioned volunteers but I’m sure it’s not all run by
volunteers.
Is it done by your staff or are you partnering homecare agencies and other
people and partners in your community, how does it work?
Darla Waldner: There are multiple partners. We do have some staff that teach classes from time to
time, but our role is more train the trainer model and we build collaborations. One of the
exciting collaborations we just finished is with the Northland Technical Community
College where I had the pleasure of being one of the facilitators of that session and we
trained OT students to do Matter of Balance.
It’s huge for their learning curve long-term and understanding the needs of the older
adult population and they did a joint Matter of Balance class in east Grand Forks that
was successful. It really depends upon who the entity in the community is. Sometimes
we partner with hospitals, which has been a lot of our strategy. Sanford Hospital itself
has actually been doing Living Well for a number of years.
Janelle Shearer: Tell us how, I think it was October 2012, where the Minnesota State Legislation came
through that when there’s a high risk patient being discharged that someone from the
hospital needs to call the senior linkage line.
Who is considered high risk?
How does that work?
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Darla Waldner: It sounds so huge, but October 1 st legislation was made that mandated for hospitals to
make referrals to the senior linkage line on all individuals that were 60+ that were
deemed to be at risk for nursing home placement. So there’s an actual screening tool
with like seven questions that the discharge planners go through and then there’s a fax
referral component to the senior linkage line.
It’s offered but that doesn’t mean that every older adult wants to engage in that
process, but it’s certain offered for those that are at risk. It has increased referrals into
our organization.
I don’t know if all hospitals yet are aware that that piece of legislation exists. Through
one of our integrative systems grants we have a staff member that has gone from
hospital to hospital educating them on this process and the reasons why. Our role is
important in bringing those home and community based services to the formal hospital
systems and support them.
That’s been a better part of 18 months where we’ve been going to hospitals to start
those conversations and build that bridge.
Janelle Shearer: So the discharge planner would do the assessment where someone is at risk for
nursing home placement and then they offer senior linkage line to that patient or
they call senior linkage line?
Darla Waldner: They make a referral. They can call. There’s a fax referral which has a protocol in place
for that. It can be both hard copy and then online to the senior linkage line and then that
person would follow up with a phone call to the patient or their family.
Janelle Shearer: Whether they go home or to a nursing home.
Darla Waldner: Yes. There’s a different process when they go to a nursing home because there’s a
pre-admission screening process and all that. There’s a process they go through with
the county and long-term care expansion.
Janelle Shearer: Has anyone with us today had experience with the senior linkage line or making
those referrals?
Guest:
Are they mandated regardless of the patients services or does that assessment
determine if they have community services or support that’s already in place
which would decrease their risk? So even if you already know they have Meals
on Wheels and have someone that checks on them, have you seen the questions
of the assessment what do they encompass?
Darla Waldner: There are questions about risk of falls, about chronic illness and things like that. So yes
based on those questions regardless of services they would be referred to us.
Guest:
So it might be as simple as that referral, them touching base with the patient or
family?
Darla Waldner: Yes. One thing to let you know of is that senior linkage line has access to MMIS which
is the county system so for those who are medical assistance eligible they would have
knowledge of the services being provided with that population.
Sherry Dale:
What we run into is that our hospitals will refer everybody to Area Agency on Aging
regardless; our discharge planner has been doing that. Our homecare clients will get
calls from Area Agency on Aging asking about all these different services which most
often they have in place, but then they’re confused as to what Area Agency on Aging is
or why they’re getting a phone call.
Darla Waldner: That’s feedback I’ve heard and it is a relatively new process.
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A lot of work through integrative systems grant is trying to educate the people about the
process and the reasons why, so thank you for that comment. What ends up happening
is a lot of this information comes out in the form of an IM that could sit on someone’s
desk and be read or not, so we’re doing our best to try and get the message out there.
Janelle Shearer: Do you think regardless of someone’s age the care transition, I think we have so many
initiatives trying to make it better that sometimes you get eight phone calls different
people like a transition coordinator, care coordinator, case manager and then there are
others who get none at all. It’s almost like a double edge sword, we either do too much
or we don’t do enough.
Darla Waldner: Hospitals are daunting too as well as Minnesota Area Agency on Aging. Often we don’t
know what the person is doing across the cubicle from us and sometimes we’re trying
to accomplish the same goals. We need to get better at communications and having
one central place.
One of the rural palliative groups I work with I have to give a plug to out of the Sanford
Center, in sitting in meetings with them and their counterparts they have lots going on
and I look at them and say what we’re talking about is care coordination, regardless of
the initiative it’s the same thing. We need to find a way where we’re all sitting at the
same table. I’m also excited because this group was selected to do a presentation at
Age Odyssey this year and they’ve done some good work and I’m proud of them.
Janelle Shearer: Thank you Darla for your presentation today.
If you have questions about this webinar, please contact Stratis Health at info@stratishealth.org.
This material was prepared by Stratis Health, the Quality Improvement Organization for Minnesota, under a contract
with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy.
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